I HAVE READ, AND I UNDERSTAND, AND I VOLUNTARILY SIGN THIS MEDICAL RELEASE/WAIVER/INDEMNITY AGREEMENT.

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1 Release/Waiver/Indemnity Agreement I, the undersigned, understand that participation in the Beta Soccer program involves certain inherent risks of injury, despite all safety precautions taken by the Beta soccer and operators. Therefore, as parent and/or guardian, I will assume all risks, injury or illness, for my child(ren) that may occur during the participation in any activities or use of facilities associated with the Beta soccer program. In the event that my child(ren) need medical treatment due to accident or injury or natural causes while registered and participating in the Beta soccer program, I authorize the Beta soccer staff and operators to take whatever action is necessary to care for my child(ren). I hereby give permission for the Beta soccer staff and operators to use their best judgment in arranging for my child(ren) s emergency medical treatment in addition to contacting me to the best of their ability. I certify that my child(ren) is/are fully covered by medical insurance and that I am fully responsible for all costs incurred due to medical or dental treatment as deemed necessary by the Beta soccer progam staff and operators. By signing this form, I acknowledge that I am aware of the potential risks of participation in any activities or use of facilities associated with the Beta soccer program, and in no way hold the Beta soccer program, its respective parent, its subsidiaries or affiliates, or their respective management, agents, employees, directors, officers, agents, volunteers or the facility or its operators, coaches, officials, or advertisers, (Individually and Collectively, the Released Parties ), liable for any injury that my child(ren) may sustain. I, FOR MYSELF, MY SPOUSE AND MY CHILD(REN), DO FURTHER RELEASE, ABSOLVE, INDEMNIFY, AND HOLD THE RELEASED PARTIES HARMLESS AGAINST ANY CLAIMS OF INJURY OR DEATH TO MY CHILD(REN) IN CONNECTION WITH ANY AND ALL OF THE ACTIVITIES MENTIONED. I HAVE READ, AND I UNDERSTAND, AND I VOLUNTARILY SIGN THIS MEDICAL RELEASE/WAIVER/INDEMNITY AGREEMENT. Parent/Guardian Name (Print) Child s Name (Print) Parent/Guardian Signature Date Model Release and Authorization to Video/Photograph As the child(ren) s parent/guardian, I hereby grant a license to the Beta soccer program, and their agents, including any advertising agencies, to use and to license others to use the child(ren) s name, recorded voice, image, picture or likeness in any live or recorded audio, video or photographic display or other transmission for purposes of promotion and publicity in connection with the Beta soccer program and any future Beta soccer events or programs. I HAVE READ, AND I UNDERSTAND, AND I VOLUNTARILY SIGN THIS MODEL RELEASE AND AUTHORIZATION TO VIDEO/PHOTOGRAPH. Parent/Guardian Name (Print) Child s Name (Print) Parent/Guardian Signature Date

Therefore, as parent and/or guardian, I will assume all risks, injury or illness, for my child(ren) that may occur during the participation in any activities or use of facilities associated with the

2 Beta Soccer Participant Enrollment Form 2014 (Please complete one form for each child.) Parent/Guardian Information Name Today s date Address City State Zip Home Phone Work Phone Cell Phone _ Relationship to Child: Parent Legal Guardian Foster parent Grandparent Sibling/Other Relative Would you be willing to volunteer? Yes No In what capacity? Coaching Events Other Participant/Child Information Name Date of Birth / / Preferred name or nickname Is this child living with you? Yes No Gender Male Female Shoe Size Shirt Size Short Size Weight Height Grade enrolled ( ) Type of School Attending: Public Charter School Faith-based Private Race/Ethnicity Asian, Native Hawaiian/Pacific Islander White, Non-Latino Other Does your child(ren) receive free/reduced price lunch at school during the school year? Yes No Primary Language Spoken at Home Secondary Language Spoken at Home (if any) Has the child participated in a Beta soccer program before? Yes No Waiver I/we, legal parent/guardian(s) of above named participant, agree to the following: 1) Give permission to the Beta soccer program to collect and record data, including Body Mass Index (BMI) weight and height and waist/neck circumference, about my child with the understanding that all information obtained will remain private, and that any responses publicly reported will be grouped together with other participants of this program and that my child will not be individually linked to his/her response. Only the staff approved by the Beta soccer will be able to view his/her responses. 2) Authorize release of data and information collected by my child s current or former school(s) to verify information and utilize information for group reporting with an understanding that only staff approved by the Beta Soccer will have access to the information. I hereby certify that the statements in this application are correct and true. Parent/Guardian Name (Print) Parent/Guardian Signature Date

Relative Would you be willing to volunteer? Yes No In what capacity?

3 Beta Soccer Padre/Tutor Legal Forma de Permiso (Por favor, completa uno para cada nino.) Informacion de Padre Nombre Fecha Dirrecion Ciudad Estado Zip Telefono Telefono de Trabajo Telefono Celular Correo Electronico: Relacion al nino: Padre Tutor Legal Padre Adoptivo Abuelo/Abuela Hermano/Hermana Quieres participar en la programa como un voluntario? Si No En que capacidad? Entrenamiento Evento Otro Informacion de Nino/Nina Nombre Dia de Cumpleanos / / Nombre preferido Este nino esta viviendo con usted? Si No Sexo Hombre Mujer Numero de Zapatos Talla de Camisa Talla de Pantalones Cortos Peso Altura Curso ( ) Tipo de Escuela : Publico Escuela de Charter Escuela Privado Raza/Etnicidad Afroamericano Indio Americano/Natural de Alaska Hispano/Latino Asiatico/Natural de Hawaii Blanco/Caucasico Otro Recibe su nino(s) almuerzo gratis o reducido? Si No Que lenguaje hablas en la casa? Hablas otras lenguajes en la casa? Cuales? Waiver Yo/nostoros, padre legal/tutor legal del nino documentado arriba, esta en acuerdo con lo siguiente: 1) Damos permiso a Beta Soccer para colectar y anotar informacion sobre el indice de masa del cuerpo (BMI), peso y altura y circumfrencia de cinturon/cuello, de me hijo child con la condicion que todo la informacion anotado se va a quedarse privado, y cualquier respuesta se va a ser agrupado con otros participantes en la programa y mi hijo nunca sera conectado a sus respuestas en un manera individuo. Solo las personas aprobado por Beta Soccer pueden ver las respuestas y informacion de mi hijo. 2.) Autorizo el suelto de informacion colectoado por la escuela(s) de me hijo para verificar informacion y usar informacion para reportajes de grupo con la acuerdo que solo los individuos aprobado por Beta Soccer se van a ver la informacion. Certifica que todo la informacion incluido en este documento esta exacto. Nombre de Padre (Letras separadas) Firma de Padre Fecha

Hermano/Hermana Quieres participar en la programa como un voluntario? Si No En que capacidad?

4 Beta Soccer Parent/Guardian Permission Form (Please complete one form for each child.) Parent/Guardian Name Participant s Name Home Phone Work Phone Cell Phone Transportation Information The Beta Soccer program will operate up to 3 day a week, after-school. Please select the following: I (or approved designee) will pick up my child after the Beta Soccer program on the following days (Circle): Monday Tuesday Wednesday Thursday Friday Saturday I allow my child to walk, bicycle or take the bus home on her/his own on his following days (Circle): Monday Tuesday Wednesday Thursday Friday Saturday Family and Emergency Contact Information Emergency/Alternative Contact (If parent or guardian cannot be reached): 1) Name Relationship to participant Home Phone Work Phone Cell Phone Does this person have permission to pick up your child? Yes No 2) Name Relationship to participant Home Phone Work Phone Cell Phone Does this person have permission to pick up your child? Yes No Please list any medical conditions or physical limitations the participant has, or special procedures that need to be followed in the event of a medical emergency: Print Name Signature Date

Please select the following: I (or approved designee) will pick up my child after the Beta Soccer program on the following days (Circle): Monday Tuesday Wednesday Thursday Friday Saturday I allow my

5 Beta Soccer Padre/Tutor Legal Forma de Permiso (Por favor, completa uno para cada nino.) Nombre de Padre/Tutor Legal Nombre de Nino Telefono Telefono de Trabajo Telefono Celular Informacion de Transportacion Beta Soccer se va a operar después de la escuela, maximo 3 dias por la semana. Yo (o un individuo aprobado) me voy a levantar mi nino/nina(s) de la escuela en estas dias (Hacer un circulo alrededor de los dias que aplica): Lunes Martes Miercoles Jueves Viernes Sabado Dejar que me hijo(s) caminan, montar en bicicleta o tomar el bus a la casa solo en las dias siguientes (Hace un circulo en las dias que aplica): Lunes Martes Miercoles Jueves Viernes Sabado Informacion de Emergencia En el evento de un emergencia y si no podemos contactar a usted, quien deberiamos contactar? 2) Nombre Relacion al nino Numero Telefonico Telefono de Trabajo Telefono Celular Esta persona tiene permiso para recoger su nino? Si No 2) Nombre Relacion al Nino Numero Telefonico Telefono de Trabajo Telefono Celular Esta persona tiene permiso para recoger su nino? Si No Por favor, si su nino tiene algunos condiciones, limites fisicas o procesos especiales que deben ser seguido en el evento de un emergencia medico, por favor hace una anotacion abajo: Nombre (con letras separadas) Firma Fecha

Yo (o un individuo aprobado) me voy a levantar mi nino/nina(s) de la escuela en estas dias (Hacer un circulo alrededor de los dias que aplica): Lunes Martes Miercoles Jueves Viernes Sabado Dejar que

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